ࡱ> OQNc  bjbj 2@ua\ua\\qNN,#0ffff|> "#$#$#$#$#$#$#$$'H#H#f|]#iii"f|r"i"#iiL6|,\^"s#0#, (/ (v (V iH#H## (N> : Specify Program or Service you are Requesting: List objectives for requested service or program: Program Date: Program Location: Program Start Time: Number of Participants Expected to Attend: Program Length: Date of Request : Requesters Name: Position/Title: Department: Phone Number: Fax: Mailing Address: Special Instructions:Additional Needs: Service Providers Name(s): Date of Presentation: Type of Program or Service Provided  Class Presentation ______Orientation _______Workshop _______RA Training _______ Group Facilitation ______Consultation _______Info Table _______Other/specify _______ Participants Fill in number and type(s):㽶ֱ students __________㽶ֱ Staff __________㽶ֱ Faculty ________Other/specify _________ I conducted an evaluation of this session YesNoNA To be filled out by person requesting program 02-16-18/bm Please mail completed requests forms to: Outreach Coordinator Counseling Center UN220 or email to:  HYPERLINK "mailto:b.menapace@csuohio.edu" b.menapace@csuohio.edu Please submit outreach requests at least 30 days prior to the program date To be completed by the staff who does the outreach Program #$-./1237cdfgjkwxz{||xnnݖnnfh%hEu: *hm8hEu:hGf *hm8hGf: *hm8h#}: hGfCJ hwb: hGf: *hhGf:h5 hvCJ hrCJ h5CJ h5: *hh5:hEu h28: hs+: hEu: *hhh: *hhEu: *hh#}:(23ghijkkd$$IflK-l-    6`0l-64 la$&`#$/Ifgdvjk{$&`#$/Ifgd?-kkd$$Iflh-l-   6`0l-64 lan\$&`#$/Ifgd?-$&`#$/Ifgd28~kd`$$Ifl0g-     6`0l-64 laweeO$&`#$/If^gd$$&`#$/Ifgd?-kd$$Ifl40g-   6`0l-64 laf4p     ! # $ % / 0 2 3 4 @ A B C F G I J K Z [ ] ^ _ s t u v h}CJ hq: *h@h}: hNj: *h$_Kh}:h} h}:CJ$ hK: h2\: h}: *hm8h}: h7: *hEuhEu: h,: *hm8h,: hwb: hEu: *hm8hEu:hEu/ $ P>,$&`#$/Ifgdv$&`#$/Ifgd?-kd$$Ifl4Fg- QH   6`0l-6    4 laf4p$ % 3 }k$&`#$/Ifgdvkd$$Ifl0g-   6`0l-64 laytxy3 4 C J q$&`#$/Ifgd?-$&`#$/Ifgdvikd$$Ifl-l-   6`0l-64 laJ K ^ p$&`#$/Ifgdv|kd$$Ifl0~-   6`0l-64 la^ _ u $&`#$/Ifgd?-ikdp$$Ifl-l-   6`0l-64 lau v $&`#$/Ifgd?-ikd$$Ifl-l-   6`0l-64 la $&`#$/Ifgd}ikd$$Ifl-l-   6`0l-64 la    " ) 6 = > ? S Y g n z   ! " N X Y ƿ׶ה hPCJ hP:CJ hP:CJ h@CJ h@:CJ h@:h@:>*CJh28:>*CJ h>A:CJh>A5:CJ\ h>A:CJ h>ACJh28 h}CJ h}:h>Ajh>ACJUmHnHu/ $&`#$/IfkkdT$$Ifl\-l-    6`0l-64 la $If$Ifikd$$Ifl-l-   6`0l-64 la   * > rrrr$&`#$/If~kd $$Ifl4-l-    6` 0l-64 laf4p > ? Z o WHHHH$&`#$/Ifkdq $$Ifl4%\@  -         6`0l-64 laf4 WBBBB$$&`#$/Ifa$gd@kdK $$Ifl4-\@  -                6`0l-64 laf4 ! _kdA $$Ifl40 -f!         6` 0l-64 laf4p $&`#$/If! " # M N R U X WBBBBBB$$&`#$/Ifa$gdACJ hUCJ h^CCJ hKCJ hCJh*<35:CJh}h>A5:CJh>AjhrCJUmHnHujhpCJUmHnHu * + A B C D R [ ` d e u v ǻ{o{k{hd@h}h>A5:CJh>Ah}h75:CJhwECJOJQJaJh2!/CJOJQJaJhZCJOJQJaJh]CJOJQJaJhQCJOJQJaJhLCJOJQJaJ h}EthV0JCJOJQJaJjhVCJOJQJUaJhVCJOJQJaJ D $a$gd8G$a$gdL p^p`gd:01h/R / =!"#$% $$If!vh#vl-:V lK 6`0l-6,5l-/  / 4$$If!vh#vl-:V lh 6`0l-6,5l-/  / 4$$If!vh#v#v:V l 6`0l-6,55/  4$$If!vh#v#v:V l4 6`0l-6,55/  / /  4f4p $$If!vh#v#vQ#vH:V l4  6`0l-6,55Q5H/  / /  4f4p$$If!vh#v#v:V l 6`0l-655/  / / / / / /  4ytxy$$If!vh#vl-:V l 6`0l-65l-/  4$$If!vh#v#v:V l 6`0l-655/  / / /  4$$If!vh#vl-:V l 6`0l-65l-/  4$$If!vh#vl-:V l 6`0l-65l-/  / 4$$If!vh#vl-:V l 6`0l-65l-/  / 4$$If!vh#vl-:V l\ 6`0l-6,5l-/  4$$If!vh#vl-:V l 6`0l-65l-/  / 4$$If!vh#vl-:V l4  6` 0l-6,5l-/  / 4f4p $$If!vh#v #v #v #v :V l4% 6`0l-65 5 5 5 /  / 4f4$$If!vh#v #v #v #v :V l4- 6`0l-65 5 5 5 /  / /  / 4f4$$If!vh#vf!#v :V l4  6` 0l-6,5f!5 /  / /  4f4p $$If!vh#v #v #v #v :V l4t 6`0l-65 5 5 5 /  / 4f4$$If!vh#v#v#v#v:V l4 6`0l-6,5555/ /  4f4s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH V@V  Heading 1 $$&`#$/@&a$ :>*CJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List <U`< = Hyperlink7>*S*Y(phP/P dcontextualextensionhighlightFVF VFollowedHyperlink >*B*phOrPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] /<4p /<4ps'@ Y  j$ 3 J ^ u > ! X  sX8  @: (    <W?Outreach Program Request FormAlbertus"?b  C "? b  C "?   B 3fdd?"? b   C  "? B S  ?YZplt(#$6(7t|t :# t jt _Hlt506554621 _Hlt50655462222@@33\\22BB]]\\22BB]]\C[:^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.[:         HQOQJMiD,y/{0r2dyQJM$X$X2{0riD,dyy/|{xya' Z]QZL?-qa7wE% ##$7% J*s+2!/*<314|50728m8J9:@BfD8G HI$_K0M^wbnfag[iNj@n'`nJoOoho2\w$v ^CGd=)rj5K7#~p,f|opEV>Ah$3zjCi\)aN}2]p#}2@11_@YKGf M\^dgnword-docGUIDdgnword-eventsink&{7E82A7E0-1946-46F0-912B-3B3B28EFE770}6780584@YYYY8@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7. [ @VerdanaA$BCambria Math"qhbbG!r4[[3QHX?fD2!xx TOPIC/PROGRAM/SERVICEKatie HBruce R Menapace Oh+'0  8 D P \hpxTOPIC/PROGRAM/SERVICEKatie HNormalBruce R Menapace3Microsoft Office Word@G@JF@*e\@\՜.+,D՜.+,@ hp|  㽶ֱ[ TOPIC/PROGRAM/SERVICE Title 8@ _PID_HLINKSAtomailto:b.menapace@csuohio.edu  "#$%&'(*+,-./0123456789:;<=?@ABCDEGHIJKLMPRoot Entry F`\RData !1Table)(WordDocument2@SummaryInformation(>DocumentSummaryInformation8FCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q